Basic Information
| Provider Information | |||||||||
| NPI: | 1992721088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18051 RIVER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460627091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177730002 | ||||||||
| FaxNumber: | 3177766095 | ||||||||
| Practice Location | |||||||||
| Address1: | 18051 RIVER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460627091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177730002 | ||||||||
| FaxNumber: | 3177766095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3175806307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0828280001 | 01 | IN | DMERC | OTHER |